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Umbilical cord Blood Analysis for Women at First Spontaneous Vaginal Delivery OBJECTIVE: To analyze the gas values of the umbilical cord blood in the first vaginal delivered babies and to verify those differences of the effects associated with obstetrical interventions including delivery mode, episiotomy, epidural anesthesia and uterine augmentation, and the other effects including prolonged duration of the second stage and excess maternal body mass index. DESIGN: A prospective descriptive study of umbilical cord artery and vein blood gas results. METHODS: During the period from August 2003 and February 2004 in the Hospital of Chung-Shan Medical University, umbilical cord blood gas results were analyzed of forty term-newborns delivered vaginally from forty health-nulliparous women. RESULTS: The mean age of 40 nulliparous woman with singleton was 27 year-old (range 15-37,SD 5.17). The mean of maternal BMI was 25.3 (range,21-32; SD, 2.51) The mean duration of second stage was 30.9 min (range 4-85,SD 20.6) The mean birth fetal weight was 2947 gm (range 2210-3720, SD 351.8).Thirty-three of forty babies was umbilical artery levels of ph7.20, and nine of forty newborns was ph7.20. Using Uni-variate logistic regression for those factors, fetal acidosis had no significant associations with those obstetric interventions which were episiotomy use (OR, 1.22 ; 95%CI, 0.21-7.11), oxytocin augmentation (OR, 1.05 ;95% CI, 0.22-5.08), vacuum extraction (OR, 3.59 ;95% CI, 0.77-16.8) and epidural anesthesia (OR, 2.67 ; 95% CI, 0.37-19.2), and the other concerned factors which were the duration of second stage (30 min) (OR, 1.73 ;95% CI,0.39-7.72) and maternal Body mass index(25) (OR, 1.88; 95% CI,0.39-8.88). After controlling the confounding factors with multi-variate logistic regression,episiotomy use (Odds Ratio, 1.096 ;95% Confidence Intervals, 0.07-16.6), oxytocin augmentation (Odds Ratio, 16.48 ;95% Confidence Interval, 1.21-226.1), vacuum extraction (Odds Ratio, 10.76 ;95% Confidence Interval, 1.025-112.9), epidural anesthesia (Odds Ratio, 0.074 ; 95% Confidence Interval, 0.003-2.09), the duration of second stage (30 min) 4

(Odds Ratio, 0.93 ;95% Confidence Interval,0.155-5.58) and maternal Body mass index(25) (Odds Ratio, 1.71; 95% Confidence Interval,0.25-11.6). Fetal acidosis had significant associations fetal acidosis with oxytocin augmentation (Odds Ratio, 16.48 ;95% Confidence Interval, 1.21-226.1) and vacuum extraction (Odds Ratio, 10.76 ;95% Confidence Interval, 1.025-112.9) The umbilical artery levels of ph of the obstetric intervention group (n=32) and non-obstetric intervention group (n=8) were 7.25 (SD, 0.076) vs 7.29 (SD, 0.039) which also had no statistic significancy ( p=0.075). CONCLUSION: Forty newborns had no neurologic defects at birth and no mortality and no morbidity during postnatal care. By measuring the umbilical blood ph, the obstetric interventions including episiotomy use, oxytocin augmentation, vacuum extraction and epidural anesthesia had no significant association with fetal acidosis (ph7.20) when using uni-variate logistic regression. Fetal acidosis had significant associations fetal acidosis with oxytocin augmentation (Odds Ratio, 16.48 ;95% Confidence Interval, 1.21-226.1) and vacuum extraction (Odds Ratio, 10.76 ;95% Confidence Interval, 1.025-112.9) when using multi-variate logistic regression. The group of obstetric interventions and the group of non-obstetric interventions also had no significant difference with fetal acidosis at birth in nulliparous women. 5

约 6

Bayer Rapidlab 248 Blood Gas Analyzer 20

phpco 2 po 2 値 HCO 3 1. ( heparin ) ( ) 2. 3. 4. 21

眞 24

Table 1: Descriptive Statistics for the Study Group (n=40) Variables Mean Std. Deviation Range Maternal age (years) 27.0 5.17 15-37 Maternal weight (kg) 63.7 5.88 52-76 Maternal height (cm) 158.8 4.70 152-171 Maternal BMI 25.29 2.51 21-32 Gestational age (wks) 38.5 1.33 36-41 Duration of second stage (mins) 30.9 20.6 4-85 Fetal cephalic circumference (cm) 32.8 1.24 30-36 Birth fetal weight (g) 2947 351.8 2210-3720 28

Table2: The means and standard deviations for umbilical vein gas analysis (n=40) Mean Std. Deviation UVpH 7.3119 0.071 UVpCO2 41.65 75 7.9491 UVpO2 26.5 6.94 UVHCO3 20.6250 2.8905 UVBDef -5.4150 3.2511 Table3: The means and standard deviations for umbilical artery gas analysis (n=40) Mean Std. Deviation UApH 7.2609 0.072 UApCO2 52.9025 9.2372 UVpO2 17.03 4.63 UAHCO3 23.2150 2.5793 UABDef -4.3775 3.0413 29

Table 4: Clinical Characteristics of Obstetrical Interventions and Arterial ph with Yate s correction Characteristic ph<7.20 (n=9) ph 7.20 (n=31) Episiotomy Yes(n=30) 8 22 No (n=10) Continuity Correction p-value 1 9 0.43 0.512 Oxytocin augmentation Yes(n=13) 5 8 No(n=27) Continuity Correction p-value 4 23 1.62 0.203 Vacuum extraction Yes(n=13) 5 8 No(n=27) Continuity Correction p-value 4 23 1.62 0.203 Epidural anesthesia Yes(n=5) 1 4 No(n=35) Continuity Correction p-value 8 27 0 1 Second stage of labor 30mins(n=18) 5 13 <30mins(n=22) Continuity Correction p-value 4 18 0.117 0.732 Maternal BMI 25(n=22) 6 16 <25(n=18) Continuity Correction p-value 3 15 0.175 0.636 30

Table 5-1: Uni-variate Logistic Regression Analysis of Fetal Acidosis (ph<7.20) Variable Odds Ratio 95% CI Episiotomy 3.27 0.35-30.1 Oxytocin augmentation 3.59 0.77-16.8 Vacuum extraction 3.59 0.77-16.8 Epidural anesthesia 0.84 0.08-8.66 Second stage of labor (30mins) Maternal BMI(25) 1.73 0.39-7.72 1.88 0.39-8.88 Table 5-2: Multi-variate Logistic Regression Analysis of Fetal Acidosis (ph<7.20) Variable Odds Ratio 95% CI Episiotomy 1.096 0.07-16.6 Oxytocin augmentation 16.48 1.21-226.1 Vacuum extraction 10.76 1.025-112.9 Epidural anesthesia 0.074 0.003-2.09 Second stage of labor (30mins) Maternal BMI(25) 0.93 0.155-5.58 1.71 0.25-11.6 31

Table 6: Statistics of Umbilical Arterial ph Umbilical arterial ph Mean Std. Deviation p-value* Obstetric interventions (n=32) 7.253 0.076 0.075 Non-obstetric interventions (n=8) 7.289 0.039 Obstetric interventions include episiotomy, oxytocin augementation, vacuum extraction and epidural anesthesia in this study. *Independent t-test Table7: The Characteristics of Fetal ph7.20 (n=9) Fetal ph 1* 7.08 2 7.148 3*+ 7.189 4 7.162 5 7.18 6 7.175 7 7.135 8 7.164 9 7.169 Apgar score Episiotomy Delivery mode Induction of labor Epidural anesthesia Duration of second stage (min) Maternal BMI 8-10 Yes VED No No 32 25 7-8 Yes VED Yes No 35 23 9-10 Yes NSD No No 15 26 8-10 Yes VED No No 67 29 8-9 Yes NSD No No 15 24 9-10 Yes NSD Yes Yes 42 22 8-10 Yes VED No No 10 29 8-10 Yes VED Yes Yes 40 25 8-10 No NSD No No 32 27 * Fetal heart rate deceleration (<60 beats per min) on fetal electrocardiogram monitoring during second stage + One true knot of fetal cord 32

Table 8: Repeated ANOVA for Blood Gas Results of 5min, 10min, and 15min at birth (n=5) Mean ph Mean pco2 Mean HCO3 Mean BDef Umbilical Vein 5min 10min 15min F value p value 7.294 7.298 7.305 0.377 0.697 38.9 38.2 37.7 0.298 0.750 18.6 18.1 18.2 0.101 0.905-7.38-7.62-7.42 - - Umbilical Artery 5min 10min 15min F value p value 7.255 7.258 7.255 0.693 0.528 54.3 50.0 47.6 2.428 0.15 23.2 21.8 20.3 3.373 0.087-4.46-5.66-6.84 - - 33

Table 8-2: Plots of Repeated ANOVA for Gas Analysis Results 8.0 Estimated Marginal Means of ph 7.8 Estimated Marginal Means of ph 7.8 7.6 7.6 7.4 Estimated Marginal Means 7.4 7.2 7.0 6.8 6.6 1 2 3 Estimated Marginal Means 7.2 7.0 6.8 6.6 1 2 3 5min of intervals (vein) 5min of intervals (artery) 39.0 Estimated Marginal Means of pco2 56 Estimated Marginal Means of pco2 38.8 54 38.6 Estimated Marginal Means 38.4 38.2 38.0 37.8 37.6 1 2 3 Estimated Marginal Means 52 50 48 46 1 2 3 5min of intervals (vein) 5min of intervals (artery) 18.7 Estimated Marginal Means of HCO3 23.5 Estimated Marginal Means of HCO3 18.6 23.0 18.5 22.5 Estimated Marginal Means 18.4 18.3 18.2 18.1 18.0 1 2 3 Estimated Marginal Means 22.0 21.5 21.0 20.5 20.0 1 2 3 5min of intervals (vein) 5 min of intervals (artery) 34

Table 9: 35

( ) No no no 11min Median no no 32min Median yes no 65min Median no no 16min Median yes no 35min Median no no 27min Median no no 11min Median no no 30min Median yes no 17min Median no no Median yes yes 60min Median no no 4min No no no No no no 42min No no no 44min No no no Median no no 67min Median no no 44min No no no 17min Median no no 58min Median no no 19min No no no 9min No no no 8min Median no no 15min Median no no 23min Median no no 15min Median yes no 23min Median yes yes 24min Median yes no 13min Median yes yes 42min Median yes no 23min 37

Median yes no 47min Median no no 10min Median yes yes 12min Median yes yes 40min Median yes no 35min No no no 32min No no no 85min Lateral no no 77min Median no no 40min 38

( ) Apgar sore fetal chart 1-5 min Head no circumference(cm) NSD 9'-10' 8226481 VED 8'-10' 8230110 NSD 8'-10' 8230482 NSD 8'-10' 1274595 VED 7'-8' 1275028 VED 8'-9' 1275067 VED 9'-10' 1275076 VED 9'-10' 8232875 NSD 9'-10' 8232905 NSD 9'-10' 1275416 NSD 8'-10' 1275372 NSD 8'-10' 1275422 VED 9'-10' 8233283 NSD 9'-10' 8233624 NSD 8'-10' 1276616 NSD 8'-10' 8235481 VED 8'-10' 8235809 NSD 8'-10' 8235884 NSD 8'-10' 8235929 VED 9'-10 8236199 NSD 8'-10' 8236334 NSD 9'-10' 8236424 NSD 9'-10' 8236699 NSD 9'-10' 8237054 NSD 9'-10' 8238769 NSD 8'-9' 1283889 NSD 9'-10' 8240016 NSD 8'-9' 8241789 NSD 8'-10' 1285100 NSD 9'-10' 8242358 NSD 8'-10' 8242396 39

NSD 9'-10' 8243322 VED 8'-10' 1286946 VED 8'-10' 1288466 VED 8'-10' 1288200 NSD 9'-10 8247712 NSD 9'-10' 8250296 VED 9'-10' 8250410 NSD 9'-10' 8251910 VED 9'-10' 8252374 40

Table 10 : 40 ( Umbilical Vein ) 41

Table 11 : 40 ( Umbilical Artery) 43